Breast Reconstruction Procedures
Following mastectomy, a tissue expander is placed underneath the pectoralis major muscle. Once expansion is completed, an outpatient procedure is performed to replace the expander with a permanent saline or silicone implant. A wide variety of saline and silicone implants are available to suit the patient’s preferences and body type. Some patients may be candidates for a single-stage implant reconstruction, in which the permanent implant is placed at the time of mastectomy.
Using implants for breast reconstruction works well for patients who do not want to undergo tissue flaps which require longer operative time and recovery. Some patients are not candidates for tissue flaps, but will do well with implants. With good quality skin coverage, implant reconstruction can achieve a pleasing, natural appearance without placing scars on other parts of the body. Disadvantages of implants include the need for multiple operations and the possibility of scarring around the implant (contracture), implant rupture, and infection. Patients who have had prior radiation therapy are usually not candidates for reconstruction with an implant alone.
Latissimus Dorsi Flap
The latissimus dorsi is a broad, flap muscle on the upper back. Along with some overlying skin and fat, this muscle can be detached and transferred to recreate a breast mound. In most patients, the muscle, fat, and skin do not provide enough tissue to recreate an adequate breast mound, and therefore an implant or expander is placed under the latissimus dorsi muscle. Using this technique, extra coverage is provided over the implant, which can result in a softer, fuller, more natural breast reconstruction. This flap is especially useful in patients who have had radiation and are not candidates for (or are not interested in) one of the abdominal flap methods, because it provides the extra skin and soft tissue that a radiated chest lacks. It is also helpful in patients who have had an implant reconstruction, receive postoperative radiation, and develop significant scarring.
Pedicle TRAM Flap (Transverse Rectus Abdominis Muscle)
Patients who have moderate excess abdominal tissue are candidates for breast reconstruction using the pedicle TRAM flap or the microsurgical techniques. The advantage of these flaps is that they replace soft, living tissue removed at the time of mastectomy with similar tissue from the abdomen. In the pedicle TRAM flap procedure, the lower abdominal fat and skin is harvested with one of the rectus abdominis muscles, which is transferred to the chest in a surgically created tunnel that connects the chest and abdomen. The muscle contains the blood vessels that supply the fat and skin, and is left attached to its origin from the lower ribs. The advantage of the pedicle TRAM flap is that it is safe, reliable, and shorter than the microsurgical procedures. The disadvantage is the higher risk of long-term abdominal problems, and a slightly higher risk of fat necrosis.
The Division of Plastic Surgery offers state-of-the-art breast reconstruction using advanced microsurgery techniques. Not every patient is a candidate for microsurgical breast reconstruction, and the best method of reconstruction is an individual decision to be made by the patient after a comprehensive consultation with one of our plastic surgeons. The advantages of microsurgical breast reconstruction include the reduced donor site morbidity and the improved blood supply. The main disadvantage is that these procedures are technically demanding and require longer operative times.
DIEP Flap (Deep Inferior Epigastric Perferator)
Perforator flaps represent the state-of-the-art in microsurgical breast reconstruction. UNC is one of only two centers in North Carolina offering such procedures. Unlike conventional TRAM flap reconstructions, use of perforator flap techniques allows for harvest of the lower abdominal tissue without sacrifice of underlying fascia and abdominal muscles. One or two blood vessels that “perforate” through the rectus abdominis muscle to supply the lower abdominal fat and skin are selected based on their size. These perforators are then gently dissected down to their source blood vessel by spreading the muscle, thereby preserving it. The abdominal tissue is then detached and transplanted to the chest where the blood vessels are reconnected using a microscope. The transplanted tissue is then surgically designed into a new breast.
M-S TRAM Flap (Muscle Sparing Transverse Rectus Abdominis Muscle)
Although many patients are good candidates for the DIEP flap, individual patient anatomy can vary. If the abdominal wall perforators are insufficient in size, then more than two perforators should be selected to supply the flap. Performing three or more perforator dissections is risky and causes damage to the muscle, thus defeating the purpose of the operation. In this situation, the multiple smaller perforators can be safely harvested with a small cuff of muscle. This is known as the Muscle-Sparing TRAM Flap, because much of the muscle is preserved. Most patients undergoing unilateral reconstruction will not notice a difference in their abdomen between the DIEP and MS-TRAM Flap.
SIEA Flap (Superficial Inferior Epigastric Artery)
In some patients, half of the lower abdominal tissue can be supported by this superficial blood vessel located between the skin and abdominal wall fascia in the groin. When present and of adequate size, the benefit of using this flap is that no incision is made in the abdominal fascia, and the muscle remains untouched. It is truly a “skin only” operation, with no risk of hernia formation or abdominal wall weakness. The disadvantage of this flap is that it cannot utilize more than one side of the lower abdominal tissue.
SGAP Flap (Superior Gluteal Artery Perferator)
Patients who are not candidates for an abdominal flap may be candidates for a flap utilizing tissue from the buttocks. The SGAP flap takes tissue from the upper buttocks based on blood vessels that “perforate” through the gluteus maximus muscle. During this procedure, the perforator vessels are gently dissected by splitting the fibers of the muscle, which is thereby preserved. This tissue is then transferred to the chest, where it is sculpted into a breast mound and reattached to blood vessels using a microscope. Bilateral breast reconstruction using the SGAP flap is usually performed in two separate operations.
Nipple and Aerola Reconstruction
Nipple and areola reconstruction can be performed following all of the above procedures, once the reconstructed breast has had time to “settle”. The nipple is reconstructed using local tissue or a tattoo, and the areola is recreated using either a skin graft or a tattoo. A discussion with your plastic surgeon will allow you to determine which method is best for you.
In addition to breast reconstruction for patients with cancer, the Division offers treatment for the following conditions:
- Congenital conditions, such as Poland syndrome and tuberous breast deformity.
- Acquired conditions, such as breast asymmetry, burns, failed implant reconstruction, symmastia, capsular contracture, implant rupture or malposition, complications of breast augmentation, and partial mastectomy defects.